Provider Demographics
NPI:1174848543
Name:MILLARD, DOLORES JEAN (RDH)
Entity Type:Individual
Prefix:MS
First Name:DOLORES
Middle Name:JEAN
Last Name:MILLARD
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SARAH LN NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-1007
Mailing Address - Country:US
Mailing Address - Phone:505-922-1040
Mailing Address - Fax:
Practice Address - Street 1:155B CAPITOL SQUARE DRIVE
Practice Address - Street 2:
Practice Address - City:ZIA PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87053-6013
Practice Address - Country:US
Practice Address - Phone:505-867-5258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM808124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11115Medicaid